Benefits of Stapled Hemorrhoidectomy Compared with Ultrasonic Dissector and Milligan's Hemorrhoidectomy

PURPOSE: Surgical hemorrhoidectomy has a reputation for being a painful procedure. Many surgical methods have been devised for reducing posthemorrhoidectomy pain. Nevertheless, the result are unsatisfactory. Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared among three hemorrhoidectomy methods. METHODS: A total of 150 consecutive patients with 3rd and 4th degree of prolapsed hemorrhoids underwent hemorrhoidectomy with stapler group (n=50) or hemorrhoidectomy with ultrasonic dissector group (n=50) or Milligan's hemorrhoidectomy using by diathermy (n=50) (by same surgeon between January and September 2001). We evaluated the difference among three techniques in operative time, postoperative pain, and patient satisfaction (using visual analogue scale). RESULTS: Mean operative time for hemorrhoidectomy with ultrasonic dissector was 19 minute; for stapler group, it was 18 minute; for Milligan's group, it was 23.6 minute (P<0.05). There was significant difference in operative time between stapler and Milligan's group. There were significant difference in pain measurement reported on immediate (5.8 for stapler, 7.2 for ultrasonic dissector, and 9.2 for Milligan's group, P<0.01), day 1 (4.3, 5.5, and 6.8, P<0.01), day 2 (3.7, 4.7, and 6, P<0.01), day 3 (3.0, 3.6, and 4.6, P<0.01), day 4 (3.1, 3.5, and 4.6, P<0.01), day 5 (2.5, 3.4, and 4.6, P<0.01), day 6 (2.0, 3.2, and 4.3, P<0.01), day 7 (1.8, 3, and 4.2, P<0.01), and defecation (4.0, 7.0, and 8.9, P<0.01). The mean analgesic (piroxicam 20 mg) requirement was 0.3 times for stapler, 1.9 for Ultrasonic dissector, and 3.1 for Milligan's group (P<0.01). Mean hospital stay was 1.6 days for stapler, 1.7 for ultrasonic dissector, 2.8 for Milligan's group (P<0.01). Patient satisfaction on day 7 was 8.2 for stapler, 6.2 for ultrasonic dissector, and 5.2 for Milligan's group (P<0.01). There was no difference in catheterization for urinary retention. It is probably due to spinal anesthesia. CONCLUSION: The study demonstrates significantly reduced postoperative pain and shorter hospital day after stapled hemorrhoidectomy compared among three groups. This resulted in an earlier return to working activities for stapled technique.

Surgical Management of Cecal Diverticulitis Detected during Appendectomy

PURPOSE: Acute diverticulitis of the right colon is not rare in Korea and the clinical presentation is indistin guishable from acute appendicitis. Cecal diverticulitis has led to a controversy in the management of disease. METHODS: Thirty-one cases of acute cecal diverticulitis who underwent operation for suspected acute appendicitis were reviewed retrospectively from January 1995 to December 1998. RESULTS: There were 17 men & 14 women. Ages ranged from 9 to 69 (mean: 37.5) years. All patients presented with signs and symptoms as acute appendicitis. All patients were explored through a transverse incision in the right lower quadrant under the impression of acute appendicitis. An appendectomy and drainage was performed in 13 patients, and resection of the lesion was performed in 18 patients (12 ileocecal resection, one partial cecectomy including appendix, one partial cecectomy and an appendectomy, 4 diverticulectomy and appendectomy), depending on the location of diverticulitis, severity of inflammation, and surgeon. Staples (TA(R), GIA(R)) were used in all cecal resection cases except for diverticulectomy. Five complications were observed, 3 in cecal resection cases (one wound seroma, one wound infection and one bleeding), and 2 in appendectomy and drainage cases (two wound infections). There was no postoperative mortality. The average length of the postoperative stay was 10.2 days in the drainage group and 8.8 days in the cecal resection group. Two recurrences were observed. One was the patient who had diverticulectomy performed. The other was a patient who had had appendectomy and drainage. CONCLUSION: We concluded that the preferred surgical management of an acute cecal diverticulitis operated for a presumed acute appendicitis is cecectomy using staples depending on its location and severity of inflammation. It was safe, relatively easy to do through the same incision, and could be a definitive treatment.

Clinical Trial Comparing Pain and Clinical Function after Conventional Semi-open Milligan Hemorrhoidectomy vs Open Ultrasonic Dissector Hemorrhoidectomy

PURPOSE:Hemorrhoidectomy is considered to be a painful operation, therefore some patients with symptomatic hemorrhoids conceal their symptoms to defer a much-needed surgical procedure. Patients who have undergone hemorrhoidectomy have experienced constipation or urinary retention due to postoperative pain. Several interventions have been used to relieve postoperative pain after hemorrhoidectomy. Nevertheless, the results are unsatisfactory. Hemorrhoidectomy with ultrasonic dissector have less thermal injury and can avoid ligation and suture. This study compared conventional semi-open Milligan hemorrhoidectomy with open ultrasonic dissector hemorrhoidectomy. METHODS:One hundred patients with prolapsed symptomatic hemorrhoids were randomly assigned to semi-open Milligan (n=50) or open ultrasonic dissector (n=50) hemorrhoidectomy. Operation time, postoperative complication, hospital stay, degree and duration of postoperative pain, pain on bowel movement, and urinary retention were recorded and analyzed. RESULTS:There was no significant difference in excised pile number. Operation time of open ultrasonic dissector hemorrhoidectomy was shorter than that of semi-open Milligan hemorrhoidectomy (P<0.05). The open ultrasonic dissector hemorrhoidectomy group resulted in less postoperative pain (P<0.05) and shorter duration of pain (P<0.05) and postoperative hospital stay (P<0.05) than semi-open Milligan hemorrhoidectomy. Urinary retention did not occur in both groups. CONCLUSIONS:Despite the higher cost, open ultrasonic dissector hemorrhoidectomy results in less postoperative pain, shorter operation time and hospital stay than the conventional hemorrhoidectomy.